Policy and Procedure
SUBJECT: Reduction Mammoplasty
DEPARTMENT: Medical Management
POLICY NO.: _____
DATE ISSUED:  _ _ / _ _/ _ _
REVISION DATES:  _ _ / _ _/ _ _
AUTHORIZED BY:                                      DATE: _ _ / _ _/ _ _

POLICY: Because breast reduction is generally cosmesis, and cosmetic surgery is not a Covered Service, all surgery involving breast reduction requires a benefit pre-determination and prior authorization with one exception--when there is a need to improve symmetry* in the contralateral breast of a medically necessary** mastectomy. However, in order to use this Benefit, when reconstruction is not performed within 12 months of the initial cancer therapy, the Member must be clear of active malignancy at the time of reconstruction.

Non-obese adult women with a Body Mass Index*** less than 25 kg/m2 may be considered for an exception to the exclusion, only when they meet the following criteria:
1. The woman has documented mammary hyperplasia, supported by a size D or greater bra cup.
2. The woman has severe and disabling neck, upper back or shoulder pain that reduces her quality of life and prevents her from performing basic activities of daily living or engaging in gainful employment.
3. The woman has no evidence by history, physical examination or imaging of underlying musculoskeletal disease or injury.
4. The pain does not respond within a period of at least six (6) months to continuous conservative management that is documented to have included anti-inflammatory analgesics, other appropriate pain management agents/regimens, body toning exercise and stretching programs.
5. The tissue removed is glandular (i.e., not adipose) at least 500 grams per breast, as documented by pathologic report. If a benefits exception is denied, the Member may submit a formal complaint for reconsideration, however this is not a Medical Necessity determination, and therefore is not eligible for Grievance.

PURPOSE: To ensure that payment for breast reduction is authorized only when specifically a Covered Service, and to allow for exceptions to be made in specific cases when mammary hyperplasia is the sole cause for a disabling pain syndrome.

Background, Intent and Definitions: "Mastectomy" means removal of more than 25% of breast tissue and must be necessitated as a result of treatment for malignancy, infection or trauma. If more than six (6) years has elapsed between the date of the mastectomy and the date of the proposed surgery, and the member has had no surgical treatment for either the primary disease or complications of the mastectomy, the reconstruction will no longer be considered "related" to the mastectomy. Mammary Hyperplasia is the presence of bilateral, symmetric glandular breast tissue far in excess of the normal range population relative to lean body mass and height.

Procedure: If the woman undergoes a mastectomy, the surgeon may submit a request for pre-authorization
1. The primary care physician PCP must perform initial evaluation and management of the pain syndrome, consulting an Orthopedic Surgeon, neurologist, or other related specialists as necessary to evaluate for possible causes of the painful condition.
2. If the patient has a BMI = or > 25, she must reduce and maintain her weight to achieve BMI of <25 for at least six (6) continuous months.
3. The PCP must refer the woman to a surgeon for evaluation and surgical treatment proposal.
4. The surgeon must provide appropriate photographs and a written report documenting breast size, and estimating the amount of glandular tissue that will be removed.
5. The Member, the PCP or the Surgeon may submit a request for an Exception to Benefit Exclusion in writing. The request must include documentation of all treatment for the pain syndrome, including a narrative of history, physical findings and treatments, (either a summary signed by the PCP, or actual copies of medical records) copies of imaging reports, photographs of breasts, and a signed statement by the PCP documenting the degree of disability due to the pain. The documentation must include current height, weight, (measured by PCP or surgeon within 30 days of the request) and weight loss history.
6. If the Member initiates the request directly, she will be notified in writing of the required documentation, and be given 30 days to get that to the NewAlliance health Plan.
7. The Medical Director or Designee will review the information submitted and render a decision within 10 business days of receiving the necessary documentation.
8. If sufficient documentation is not received within 30 calendar days of the initial request, NewAlliance will render a decision based on documentation submitted to date.
9. If the Member is unable to secure the necessary documentation, she may ask for an extension of up to another 30 calendar days, after which a final decision will be rendered.
10. If the Exception to Benefits Exclusion is not granted, the Member may request reconsideration through the standard complaint process.

Footnotes:
* It is noteworthy that some amount of breast asymmetry is the norm.

** E.G., for the management of breast or related lymph node cancer, infection, or trauma. However, when the "trauma " is iatrogenic, particularly from a cosmetic procedure, it will be reviewed on a case-by-case basis.

*** Body Mass Index (BMI) is calculated by taking the body weight in kilograms and dividing it by the height in square meters. It can be derived from a standard chart or nomogram.